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Tracheostomy

Introduction

A tracheostomy is a surgical procedure to create an opening in the neck at the front of the trachea (windpipe).

A tube (called a tracheostomy tube) is inserted through the opening and connected to an oxygen supply to assist with breathing.

It can also be used to remove fluid that has built up in the throat and windpipe.

A tracheostomy can be performed as:

  • an emergency procedure – for example, if someone is unable to breathe following an injury or accident
  • a planned procedure – to help someone who can't breathe normally because of a long-term condition such as multiple sclerosis

Read more about why a tracheostomy is necessary.

If it’s an emergency, the tracheostomy will be carried out at the site of the accident or in the nearest hospital’s accident and emergency department. Local anaesthetic may be used if there is not enough time to use general anaesthetic.

Planned tracheostomies are usually carried out in an operating theatre using general anaesthetic.

Read about how a tracheostomy is performed.

Is a tracheostomy permanent?

A tracheostomy may be temporary or permanent.  When it's possible for a person to breathe unaided, the tracheostomy tube can be removed. The opening will usually close on its own within one to two weeks, leaving a small scar. If it doesn’t close on its own, it can be closed using stitches.

The tube may need to stay in permanently if a person has a long-term condition that makes it difficult for them to breathe unaided.

Safety

A tracheostomy is a safe and effective procedure. However, as with all medical procedures, there is a small risk of complications, such as bleeding and infection.

Read more about any complications of a tracheostomy that could arise.

Living with a tracheostomy

It's possible to enjoy a normal lifestyle with a permanent tracheostomy tube. However, adapting to life with a tracheostomy tube can take some time and most people will initially have difficulty with activities such as:

  • talking
  • eating
  • keeping the tracheostomy tube clean and free of blockages

If you or your child needs to have a tracheostomy, a specially trained nurse will be available to give you advice and answer any questions that you have.

Great Ormond Street Hospital for Children also has a comprehensive guide about living with a tracheostomy. 

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Why is it necessary?

Tracheostomy is normally performed:

  • to deliver oxygen to the lungs when a person is unable to breathe normally – the loss of normal lung function is called respiratory failure (see below)
  • to bypass an airway that has become blocked
  • to remove fluid from the windpipe (trachea) and throat that has built up in the upper airway

These are discussed below.

Respiratory failure

There are many conditions that can lead to respiratory failure and the need for a tracheostomy. Examples are:

  • being unconscious or in a coma as a result of a severe head injury, drug overdose or accidental poisoning
  • brain damage caused by a stroke or a severe head injury
  • paralysis (an inability to move one or more muscles) after a serious neck or spinal injury
  • a condition that causes extensive damage to the lungs, such as pneumonia or cystic fibrosis (where the lungs become clogged up with mucus)
  • a condition that causes progressive damage to the nervous system, such as motor neurone disease or Guillain-Barré syndrome (both conditions can lead to paralysis and breathing difficulties)

Blockage

The airways can be blocked due to:

  • accidentally swallowing a foreign body that gets stuck in the windpipe, such as a piece of bone
  • an injury, infection, burns or a severe allergic reaction (anaphylaxis) that causes the throat to become swollen and narrowed
  • a cancerous tumor that blocks one or more airways - this can sometimes happen with mouth cancer, laryngeal cancer or thyroid cancer

In addition, some children are born with birth defects that cause one or more of their airways to be abnormally narrow.

Fluid

There are several factors that can cause fluid to build up inside the airways and lungs, resulting in breathing difficulties. There is also a danger that the fluid could become infected.

In some circumstances, it may be necessary to carry out a tracheostomy so the fluid can be sucked out through the tracheostomy tube. This may be necessary when the person:

  • is unable to cough properly due to chronic pain, muscle weakness or paralysis
  • has a serious lung infection, such as pneumonia, that has caused their lungs to become clogged with fluid
  • has an injury that has resulted in their airways or lungs becoming filled with blood
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How is it performed?

A tracheostomy is carried out as one of the following:

  • an emergency procedure – for example if someone is unable to breathe following an injury or accident
  • a planned procedure – to help someone who cannot breathe normally because of a long-term condition

The emergency and planned tracheostomy procedures are discussed in more detail below.

An emergency tracheostomy may be needed if a person’s airway suddenly or unexpectedly becomes blocked following an accident or injury.

It may also be required if someone has respiratory distress syndrome (a serious and life-threatening condition where the lungs cannot provide enough oxygen for the rest of the body).

An emergency tracheostomy may need to be performed under a local anaesthetic if there is not enough time for a general anaesthetic or if the tracheostomy is being performed outside of a hospital.  If local anaesthetic is used, the person will be awake throughout the procedure and will not feel any pain.

Trained healthcare professionals, such as paramedics, are able to perform an emergency tracheostomy very quickly.  The person undergoing the tracheostomy is positioned on their back and a rolled-up towel (or equivalent) placed under their shoulders to help stretch out their neck and make it easier to see the structures in the throat. An incision is then made through the skin of the neck and underlying tissue. The tracheostomy tube is inserted into the airway and connected to a ventilator (a machine that supplies oxygen supply to assist with breathing). 

Planned tracheostomy

A planned tracheostomy can be carried out in one of two ways:

  • a percutaneous tracheostomy
  • an open tracheostomy

Both procedures are described below. 

Percutaneous tracheostomy

A percutaneous tracheostomy is usually carried out under local anaesthetic. The surgeon will make a small cut in the throat (about 1.5cm to 2cm long) and use a surgical instrument called a dilator to keep the incision open. The tracheostomy tube is inserted through the incision and guided into place using a wire.

After the procedure, an X-ray may be taken to check that the tube is in the right position. Antibiotics may be prescribed to reduce the risk of an infection at the site of the incision.

Open tracheostomy

An open tracheostomy is normally carried out under a general anaesthetic in an operating theatre.  This means you are asleep during the procedure and will not feel any pain.

The surgeon makes an incision in the lower part of the neck between the Adam’s apple and the top of the breastbone.  The neck muscles are then parted and the thyroid gland cut or moved so that the surgeon has a clear view of the windpipe. The surgeon then makes an incision through the wall of the windpipe so that the the tracheostomy tube can be inserted into the opening.  If you are unable to breathe unaided, the tube can be attached to a ventilator to increase the flow of oxygen to your lungs.

After the tracheostomy tube is in position, a dressing is placed around the opening in the neck and tapes or stitches are used to hold the tracheostomy tube in place.

Percutaneous versus open tracheostomy

The preferred option for a planned tracheostomy is the percutaneous technique. This carries the least risk of complications.

An open tracheostomy will be carried out when it is not safe or feasible to perform a percutaneous tracheostomy.

It may be recommended:

  • for children younger than eight years old
  • when the normal structure of the neck has been affected by something, such as a tumour or a collection of blood
  • when the person is very overweight and has a large amount of fat in and around their neck
  • if there is an infection inside the neck or surrounding tissue 
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Complications

Having a tracheostomy is considered to be a safe and straightforward procedure, but as with many medical procedures it does carry a risk of complications.

The likelihood of complications occurring will depend on your age and general health, and the reason why you need the tracheostomy. Generally, a planned tracheostomy carries a lower risk of complications than an emergency tracheostomy, and a percutaneous tracheostomy carries a lower risk than an open tracheostomy.

Early complications

Complications that can occur during or shortly after a tracheostomy are outlined below.

Collapsed lung

Sometimes, air will collect around the lungs and cause the lungs to collapse inwards. This is known as a pneumothorax. In mild cases this often corrects itself without the need for treatment. In more serious cases, a tube will need to be surgically implanted into the chest to drain the air away from the lungs.

Accidental injury

The nerves near the windpipe can be accidentally damaged, such as those controlling the voicebox (larynx) or the oesophagus (tube that runs from the back of the throat to the stomach). This may cause problems with speaking and swallowing.

Infection

The windpipe or nearby tissues can become infected with bacteria. These usually need to be treated with antibiotic injections.

Late complications

Complications that can occur days, weeks or even months after a tracheostomy are described below.

Failure to heal

Sometimes, the tracheostomy wound will not heal properly and starts to bleed. If this happens, the tracheostomy tube may need to be temporarily removed so that surgery can be carried out to stem the bleeding.

Collapsed windpipe

Sometimes, the windpipe collapses in on itself because the walls of the windpipe are not strong enough to support it. This usually occurs when the tracheostomy tube has not been fitted properly, and it requires further surgery.

Breathing difficulties

Any form of accidental damage to the throat can result in the airways becoming narrowed, which can cause breathing difficulties. Surgery may be needed to widen the airways. This may involve implanting a small tube, called a stent, to keep the airways open.

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Recovery

It's possible to enjoy a normal lifestyle with a permanent tracheostomy tube.

You will be able to resume everyday activities without difficulty, but you should avoid vigorous activities for about six weeks after the procedure.

When you're outside, it's very important that your tracheostomy opening is kept clean and dry. The opening will usually be covered with a dressing, but a loose piece of clothing, such as a scarf, can also be worn over the top. This will stop substances such as water, sand or dust from entering the opening and causing breathing problems.

Speech

It is usually difficult to speak after having a tracheostomy. Normally, speech is generated when air passes over the vocal cords at the back of the throat. After a tracheostomy, most of the air that you breathe out will pass through your tracheostomy tube rather than over your vocal cords, which means you will be unable to speak normally.

One solution is to use a speaking valve, which is a plastic attachment that sits at the end of the tube and is designed to temporarily close over every time you breathe out. This prevents the air leaking out of the tube and allows you to speak. However, it can take a while to get used to speaking with the valve.

After having a tracheostomy, you may be referred to a speech and language therapist. They will be able to give you further advice and training in speaking while the tracheostomy tube is in place so that you can improve your ability to communicate.

Cleaning the tracheostomy tube

A tracheostomy tube needs to be cleaned whenever it gets blocked with mucus or fluid. The tube may need to be cleaned several times a day.

If the tube is permanent, or if you are allowed to return home with the tube still in place, a specialist tracheostomy nurse will teach you how to take care of the tube. They will show you how to suction fluid from your windpipe (trachea) and how to clean and change your tracheostomy tube.

Removing the tracheostomy tube

If you have a temporary tracheostomy, the tube will need to be removed when you are able to breathe freely and unaided.

After the tracheostomy tube has been removed, the opening in your neck will be covered with a dressing. The opening will usually take one to two weeks to heal and afterwards you may have a small scar where the opening was. If the opening does not close on its own, stitches may be needed to close it.

Over time, a tracheostomy opening tends to narrow, so if you have a long-term or permanent tracheostomy tube, you may need to have further surgery to widen it.

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